Leave no one behind: response to new evidence and guidelines for the management of cryptococcal meningitis in low-income and middle-income countries

In 2018, WHO issued guidelines for the diagnosis, prevention, and management of HIV-related cryptococcal disease. Two strategies are recommended to reduce the high mortality associated with HIV-related cryptococcal meningitis in low-income and middle-income countries (LMICs): optimised combination therapies for confirmed meningitis cases and cryptococcal antigen screening programmes for ambulatory people living with HIV who access care. WHO's preferred therapy for the treatment of HIV-related cryptococcal meningitis in LMICs is 1 week of amphotericin B plus flucytosine, and the alternative therapy is 2 weeks of fluconazole plus flucytosine. In the ACTA trial, 1-week (short course) amphotericin B plus flucytosine resulted in a 10-week mortality of 24% (95% CI −16 to 32) and 2 weeks of fluconazole and flucytosine resulted in a 10-week mortality of 35% (95% CI −29 to 41). However, with widely used fluconazole monotherapy, mortality because of HIV-related cryptococcal meningitis is approximately 70% in many African LMIC settings. Therefore, the potential to transform the management of HIV-related cryptococcal meningitis in resource-limited settings is substantial. Sustainable access to essential medicines, including flucytosine and amphotericin B, in LMICs is paramount and the focus of this Personal View

Educational intervention to improve antibiotic knowledge at Kamuzu Central Hospital, Malawi

Background: Antibiotic resistance is a global issue that has the potential to significantly affect countries with limited antibiotic choices. At many government hospitals in Malawi, including Kamuzu Central Hospital (KCH), limited laboratory data and antibiotic options are barriers to providing appropriate antibiotics to patients. We aimed to design an educational intervention targeted to Malawian clinician trainees, including registrars, interns, and medical students, with the goal of improving their knowledge of appropriate antibiotic use based on available clinical information and Malawian guidelines. Methods: As part of an institutional partnership between the University of California—Los Angeles (UCLA) and KCH, an educational intervention was carried out at KCH in January, 2017. The intervention was designed and conducted by UCLA internal medicine-paediatrics residents, with supervision from a UCLA infectious disease specialist and KCH medical leadership. The intervention included a teaching session that reviewed common clinical infections, antibiotic options, duration of therapy, and detailed information regarding antibiotics commonly used in Malawi. Malawian trainees were supplied with an antibiotic prescribing pocket guide which summarised best practices from the Malawi Standard Treatment Guidelines, taking into account the hospital's drug formulary. Trainees were also provided with an algorithmic guide to aid decision-making for initiation of empirical antibiotics based on a patient's clinical presentation. Prior to the educational module, participants completed a multiple-choice survey to assess their baseline knowledge of appropriate antibiotic use for multiple case-based scenarios. A post-intervention survey was performed 2 weeks later, followed by a didactic session to review the correct answers for the cases and reinforce the intervention content. Findings: 33 pre-intervention surveys and 31 post-intervention surveys were completed. Of the 22 trainees who completed both surveys, the majority were medical students (n=16) and interns (n=4). Paired t-test analysis of the pre-test and post-test results showed a mean 17% increase in test scores (p<0·0001), which equates to an average of 2·4 more cases treated correctly. Interpretation: Brief, focused global health educational initiatives such as this may be able to provide local trainees with the knowledge to achieve best practices regarding antibiotic use. Ongoing educational initiatives are planned related to antimicrobial stewardship and other key clinical topics relevant to Malawi. Funding: None

Application of the qSOFA score to predict mortality in patients with suspected infection in a resource-limited setting in Malawi

To determine the predictive value of qSOFA (quick Sequential Organ Failure Assessment) in Malawian patients with suspected infection. Prospective observational study in a tertiary referral hospital in Malawi. Predictive ability of qSOFA was reasonable [AUROC 0.73 (95% CI 0.68-0.78)], increasing to 0.77 (95% CI 0.72-0.82) when classifying all patients with altered mental status as high risk. Adding HIV status as a variable to the qSOFA score did not improve predictive value. qSOFA is a simple tool that can aid risk stratification in resource-limited setting